# Robotic Right Lower Lobectomy in a Patient With V2 and V4+5 Pulmonary Vein Variation Merging Into the Lower Pulmonary Vein: A Case Report

## TL;DR

A case report describes a robotic lobectomy in a patient with unusual pulmonary vein anatomy, highlighting the importance of preoperative imaging to avoid surgical complications.

## Contribution

The paper presents a novel case of V2 and V4+5 pulmonary vein variation and demonstrates how preoperative 3D-MDCT can guide safe robotic lobectomy.

## Key findings

- Preoperative 3D-MDCT accurately identified the merging of V2 and V4+5 into the lower pulmonary vein.
- Dividing the lower lobe pulmonary vein after oblique fissure separation prevented transection of preserved anomalous veins.
- Detailed understanding of vascular anatomy is essential for safe robotic lobectomy in patients with PV variations.

## Abstract

Several variations of pulmonary vein (PV) branching patterns exist. Since robot-assisted thoracoscopic surgery (RATS) is performed with magnified vision, it is crucial to carefully identify the running pattern of blood vessels before and during surgery. We present a case of a 77-year-old male patient with right lower lobe lung cancer. Right lower lobectomy via RATS was scheduled. Chest CT before surgery confirmed that the middle lobe PV (V4+5) merged with the inferior PV. Three-dimensional multidetector CT (3D-MDCT) subsequently confirmed that not only V4+5 but also the posterior segmental vein of the upper lobe (V2) merged with the inferior PV. We should have taped the lower lobe PV only, but we also taped the V2 and the middle lobe vein. However, since the oblique fissure was separated before cutting the taped blood vessel, the cutting of the blood vessel to be preserved was avoided.

Surgeons should have a detailed understanding of the running patterns of pulmonary blood vessels before surgery to perform the procedure safely. Preoperative 3D-MDCT is useful for identifying the running pattern of blood vessels. An abnormality involving V2 and V4+5 merging into the inferior PV can also occur; hence, during right lower lobe resection, by dividing the lower lobe PV after the oblique fissure division, the surgeon can avoid unexpected transection of anomalous PVs that should be preserved.